INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 31, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Lehigh Valley Drug and Alcohol Intake Unit was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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709.28 (c) (4) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on release of information forms in five of eight client records reviewed.
Client #1 was admitted on November 23, 2020 and was discharged on November 23, 2020. Every release of information form in the client record failed to document the dated physical signature of the client.
Client #3 was admitted on February 2, 2022 and was discharged on February 2, 2022. Every release of information form in the client record failed to document the dated physical signature of the client.
Client #4 was admitted on April 8, 2021 and was discharged on April 8, 2021. Every release of information form in the client record failed to document the dated physical signature of the client.
Client #5 was admitted on December 9, 2021 and was discharged on December 9, 2021. Every release of information form in the client record failed to document the dated physical signature of the client.
Client #8 was admitted on December 4, 2020 and was discharged on December 4, 2020. Every release of information form in the client record failed to document the dated physical signature of the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has obtained waivers from other funding sources to obtain verbal consent, however it is our intention to properly obtain physical signatures on all documentation as it relates to confidentiality 709.28(c) (4) . The facility will request a waiver to DDAP for special circumstances where verbal consent may be allowed when conducting a Telehealth assessment. If not approved, the facility will implement and invest in a software (docusign) where the physical signatures may be obtained. The clinical supervisor will do an in-service to train staff on how to use this technology starting on 5/1/22, the supervisor will conduct monthly chart reviews on every assessor to ensure that these signatures are obtained and verbal consent will no longer be an option/issue. |
709.44(b)(4) LICENSURE Follow-up Information
709.44. Client records.
(b) If applicable, the project shall also include the following items in the client record:
(4) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document, in the complete client record, follow-up information in four of six applicable client records reviewed.
Client #1 was admitted on November 23, 2020 and was discharged on November 23, 2020. There was no follow-up information documented in the record at the time of the inspection.
Client #2 was admitted on August 10, 2021 and was discharged on August 10, 2021. There was no follow-up information documented in the record at the time of the inspection.
Client #3 was admitted on February 2, 2022 and was discharged on February 2, 2022. There was no follow-up information documented in the record at the time of the inspection.
Client #5 was admitted on December 9, 2021 and was discharged on December 9, 2021. There was no follow-up information documented in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will assign a specific procedure to Case Managers or equal staff that involves the following:
-Effective 5/1/22, staff will conduct follow ups on a weekly basis and document attempts made to confirm that intake appointment was kept with treatment provider on all referrals. The Case Manager Supervisor will review monthly cases to ensure that that we have attempted to follow up once referral has been sent.
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